Faculty Bibliography

BACKGROUND:Chronic axial spinal pain is a major contributor to disability and healthcare expenditures, with facet joints recognized as one of the established sources of pain. OBJECTIVE:To provide evidence-based guidance in performing diagnostic and therapeutic facet joint interventions. METHODS:A multidisciplinary panel of experts from various medical and pharmaceutical disciplines, convened by the American Society of Interventional Pain Physicians (ASIPP), reviewed the available evidence, considered patient perspectives, and formulated recommendations for facet joint interventions in the management of chronic pain.The methodology included the development of key questions with evidence-based statements and recommendations. Grading of the evidence and recommendations followed a modified approach described by ASIPP, the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology, and the Agency for Healthcare Research and Quality (AHRQ) methods for grading strength of recommendations. The evidence review included existing guidelines, systematic reviews, comprehensive reviews, randomized controlled trials (RCTs), and observational studies evaluating the effectiveness and safety of facet joint interventions in chronic pain management.In the development of consensus statements and guidelines, a modified Delphi technique was utilized to minimize bias related to group interactions. Panelists without a primary conflict of interest voted on approval of specific guideline statements. Each panelist was permitted to suggest revisions to guideline wording and provide additional qualifying remarks or comments regarding implementation of the guidelines in clinical practice. To achieve consensus and inclusion in the final guidelines, each guideline statement required at least 80% agreement among eligible panel members without a primary conflict of interest. RESULTS:A total of 48 authors participated in the development of these guidelines, of whom 39 participated in the voting process. A total of 37 recommendations were developed, with 100% acceptance for all items. The Summary of Recommendations is presented separately. These recommendations addressed diagnostic, therapeutic, and special considerations related to facet joint interventions. For diagnostic and therapeutic interventions, the level of evidence ranged from II to III, with moderate to strong recommendations. For special considerations and safety assessments, the level of evidence ranged from II to V. The evidence provided recommendations regarding diagnosis, treatment, sedation, concurrent antithrombotic therapy, and precautions required in special clinical circumstances. LIMITATIONS/CONCLUSIONS:The limitations of these guidelines include a paucity of high-quality studies in some aspects of diagnosis and therapy. CONCLUSION/CONCLUSIONS:These guidelines for facet joint interventions were developed through a comprehensive review of the literature, including methodologic quality assessment and determination of the level of evidence and strength of recommendations. DISCLAIMER/CONCLUSIONS:These guidelines are based on the best available evidence and do not constitute inflexible treatment recommendations. Due to the changing body of evidence, this document is not intended to be a "standard of care."

BACKGROUND:Chronic axial spinal pain is one of the leading causes of disability. The literature demonstrates that expenditures for low back and neck pain continue to rise, not only in parallel with increasing disability, but also with escalating healthcare costs, accounting for the highest spending among multiple disease categories. Based on current evidence utilizing controlled diagnostic blocks, facet joints, nerve root dura, and sacroiliac joints have been identified as potential sources of spinal pain. STUDY DESIGN/METHODS:A systematic review of the diagnostic accuracy of spinal facet joint nerve blocks. OBJECTIVE:To determine the diagnostic accuracy of spinal facet joint nerve blocks in chronic spinal pain. METHODS:Methodological quality of the included studies was assessed using the Quality Appraisal of Reliability Studies (QAREL) instrument. Only diagnostic accuracy studies meeting at least 50% of the predefined inclusion criteria were included in the analysis.The strength of evidence was graded using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) criteria. Levels of evidence were classified using a modified best evidence synthesis, ranging from Level I to Level V.Data sources included relevant literature identified through PubMed and other electronic searches published from 1966 through September 2025, Cochrane reviews, and manual searches of the bibliographies of primary and review articles. OUTCOME MEASURES/METHODS:Eligible studies were required to use placebo-controlled or comparative local anesthetic blocks. A positive diagnostic standard was defined as at least 50% pain relief from baseline scores along with the ability to perform previously painful movements. RESULTS:The available evidence demonstrated Level I for lumbar facet joint nerve blocks, based on 18 studies employing dual diagnostic blocks, demonstrating 75% to 80% pain relief, with an average prevalence of 16% to 45% and estimated or presumed false-positive rates of 25% to 50%.Evidence for the diagnosis of cervical facet joint pain using cervical facet joint nerve blocks is Level II, derived from 12 controlled diagnostic accuracy studies, showing substantial heterogeneity and internal inconsistency. Reported prevalence ranged from 36% to 67% with ≥ 80% pain relief and estimated or presumed false-positive rates of 26% to 63%.The level of evidence for the diagnostic accuracy of thoracic facet joint nerve blocks is Level II, based on 3 studies using dual diagnostic blocks, demonstrating 80% or greater pain relief, with prevalence ranging from 34% to 48% and estimated or presumed false-positive rates ranging from 42% to 58%. LIMITATIONS/CONCLUSIONS:Limitations of this systematic review include the limited number of studies involving the thoracic spine, ongoing debate regarding the appropriate reference standard, challenges in determining false-positive rates, concerns regarding the appropriateness of diagnostic blocks, the scarcity of recent publications, and issues related to clinical utility. CONCLUSION/CONCLUSIONS:There is Level I evidence for the diagnostic accuracy of lumbar facet joint nerve blocks and Level II evidence for cervical and thoracic facet joint nerve blocks in the evaluation of chronic spinal pain.

BACKGROUND:Recent analysis of epidural procedure utilization has demonstrated significant shifts over the past 25 years. Utilization increased substantially until 2004, continued with modest growth through 2011, and then gradually declined through 2019 among the Medicare population. Influences from the COVID-19 pandemic, the Affordable Care Act (ACA), and economic pressures have continued to contribute to declining utilization patterns. OBJECTIVE:The present investigation provides an updated evaluation of epidural procedure utilization for chronic pain management in the U.S. Medicare population, focusing on the time periods of 2000 to 2010, 2010 to 2019, and 2019 to 2024. STUDY DESIGN/METHODS:A retrospective cohort study evaluating utilization patterns and variables for epidural injections in the fee-for-service (FFS) traditional Medicare population in the U.S. from 2000 to 2024. METHODS:A retrospective longitudinal analysis of Medicare Part B data from 2000 through 2024 was completed. Epidural injection services included cervical/thoracic and lumbar/caudal interlaminar injections, and cervical/thoracic and lumbar/sacral transforaminal injections, identified using procedure codes in the study database. A procedure or service represented all interventions performed during a treatment episode, incorporating add-on codes and bilateral services. Episodes were defined as one unit regardless of bilateral or additional services, reflecting the number of times patients received treatment. Utilization was assessed through counts, rates per 100,000 beneficiaries, geometric mean changes, and percent changes across key intervals (2000-2010, 2010-2019, 2019-2024). Trends by provider's specialty and place of service were also evaluated. RESULTS:From 2000 to 2010, services, episodes, and rates per 100,000 beneficiaries increased 144.3%, 126.1%, and 103%. From 2010 to 2019, this pattern shifted to declining utilization, with reductions of 9.5% in services, 0.4% in episodes, and 9% in rates per 100,000. From 2019 to 2024, procedural rates declined 13%, episodes declined 22.6%, and episode rates declined 11.9%, corresponding to average annual reductions of 2.8%, 4.3%, and 2.6%.Comparative analysis showed that from 2000 to 2010, interlaminar epidural rates increased 43.8%, whereas transforaminal epidural rates increased 579.1%. From 2010 to 2019, interlaminar rates declined 18.4%, while transforaminal rates increased 5%. From 2019 to 2024, interlaminar rates declined 14.6% compared to 8.7% for transforaminal procedures. By 2024, interventional pain specialists performed over 92% of all epidural injections, while other specialties showed decreasing participation. A continued shift toward office settings and ambulatory surgery centers (ASCs) was also observed. LIMITATIONS/CONCLUSIONS:The study includes data only through 2024 and is limited to the FFS Medicare population, excluding Medicare Advantage beneficiaries who accounted for 54% of Medicare enrollment by 2024. Limitations inherent to retrospective claims data also apply. CONCLUSION/CONCLUSIONS:Epidural injection utilization has shifted substantially over the last 25 years, driven by changes in clinical practice, regulatory and economic influences, and pandemic-related disruptions. The increasing concentration of procedure utilization among interventional pain specialists, together with the continued expansion of transforaminal techniques, underscores the progressive specialization and refinement of interventional pain management within the Medicare population.

BACKGROUND:Regenerative medicine is an evolving medical subspecialty dedicated to enhancing the body's natural healing mechanisms to repair or replace damaged tissues. By using autologous or allogeneic biologics, it offers the potential to restore function where conventional therapies have shown limited success. While this field holds great promise and continues to generate enthusiasm among both patients and clinicians, it remains in early stages of clinical validation. Therefore, it must be approached with careful optimism and responsible application, ensuring that its presentation, promotion, and use in clinical settings are grounded in evidence and ethical standards. OBJECTIVE:To provide updated, evidence-based recommendations for the role of regenerative therapies in managing moderate to severe chronic low back pain. METHODS:A multidisciplinary panel of experts, convened by the American Society of Interventional Pain Physicians (ASIPP), systematically reviewed the current evidence and incorporated patient perspectives to develop practical, evidence-informed recommendations. The process included defining key clinical questions, reviewing the literature, formulating evidence-based statements, and reaching consensus through structured discussions and formal voting. RESULTS:A total of 35 authors contributed to the development of these guidelines, with 33 experts participating in the formal consensus process. Altogether, 19 recommendations were generated, with all of them achieving 100% agreement. These recommendations were informed by a comprehensive review of systematic reviews, randomized controlled trials (RCTs), and observational studies encompassing a broad range of regenerative therapies.Evidence was appraised using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology to determine certainty levels. Both qualitative and quantitative analyses were applied to synthesize the best available data, resulting in evidence-based recommendations summarized below.Intradiscal Injections (PRP): Evidence Level: III, Fair; Consensus-Based Clinical Recommendation: ModerateIntradiscal Injections (BMAC): Evidence Level: III, Fair; Consensus-Based Clinical Recommendation: ModerateEpidural Injections (PRP): Evidence Level: III, Fair; Consensus-Based Clinical Recommendation: ModerateFacet Joint Injections (PRP and MSCs): Evidence Level: IV, Limited; Consensus-Based Clinical Recommendation: Moderate Sacroiliac Joint Injections (PRP): Evidence Level: IV, Limited; Consensus-Based Clinical Recommendation:  Low Functional Spine Unit Injections Evidence Level: Very Low; Consensus-Based Clinical Recommendation:Low. LIMITATIONS/CONCLUSIONS:The primary limitation of these guidelines is the scarcity of high-quality studies, with much of the available evidence derived from small or heterogeneous trials. PRECAUTIONS/UNASSIGNED:Regenerative therapies should be considered only after a thorough diagnostic evaluation confirming clinical necessity. Treatment decisions must account for the patient's medical condition, preferences, and expectations. Patients should be fully informed about the nature, potential benefits, risks, and costs of regenerative treatments, most of which are not covered by commercial insurance.These therapies may be used alone or in conjunction with other evidence-based modalities, such as structured exercise, physical therapy, behavioral therapy, or conventional medical management. Clinicians must follow all applicable U.S. Food and Drug Administration (FDA) regulations and adhere to safety and ethical standards outlined in these guidelines. CONCLUSION/CONCLUSIONS:Based on current evidence, lumbar intradiscal injections of platelet-rich plasma (PRP) and mesenchymal stem cells (MSCs) are supported by Level III evidence. Lumbar epidural PRP injections are also supported by Level III evidence, while PRP injections for lumbar facet joints and sacroiliac joints are supported by Level IV evidence. Given the emerging status of biologic therapies and the limited quality of existing studies, the panel provides moderate, consensus-based recommendations for the use of all biologics in the lumbar spine.

On July 14, 2025, the Centers for Medicare and Medicaid Services (CMS) released the 2026 Physician Proposed Payment Rule aimed at reducing wasteful spending, enhancing quality measures, improving chronic disease management, and protecting independent practices from systemic financial pressures that have favored large healthcare systems and plagued independent practices. The goals are admirable, but the proposed measures with uniform reductions of 2.5% in physician payments based on efficiency adjustments apply across the board to all physicians. Further, practice expense (PE) reductions of 4% to 6%, meant to apply for hospital-based physicians will inadvertently apply to independent physicians constituting 43% of the physician workforce providing services in ambulatory surgery centers (ASCs), as well as hospitals. Thus, reductions of work relative value unit (wRVU) based on efficiency adjustment of 2.5% and PE reductions of 4% to 6%, with total reductions of 7% to 9%, compromise and limit patient care by putting additional pressure on independent physicians. Further, CMS' proposal to start Ambulatory Specialty Model (ASM) for low back pain with specialties of interventional pain management (IPM) and pain management involved. These specialties have no control over costs incurred as an overwhelming majority of patients are chronic pain patients and managed by family physicians, chiropractors, physical therapists, neurosurgeons, and others, resulting in 9% reductions, or increase in reimbursement over a period of 3 years with recurring changes of 3% each year.The proposal includes a 3.8% conversion factor (CF) payment update and increased reimbursement for office-based services, including evaluation, management, and procedures. The changes will increase reimbursement by 8% to 10% for office-based services, but they also decrease reimbursement for all procedures performed outside offices by 7% to 9%. These proposals arrive at a time when non-physician health care providers are striking for wage increase tied to inflation, and ironically, physicians have experienced repeated cuts in reimbursement with occasional stagnation, leading to 33% reduction from 2001 to 2025 in general, and 41% reductions in reimbursement for interventional pain physicians. In addition, there is an additional 2% sequester cut each year from 2011 to last until 2031, and there is a potential for 4% PAYGO cuts starting next year. Further, supply costs have increased 56% to 80% during these years. Further, despite technological advancements such as EMRs and AI, administrative burdens have intensified rather than improved. Independent physicians contend with complex prior authorizations, evolving Medicare coverage policies, growing audit risk with increased documentation and compliance demands from all payers' sources, 30% of interventional pain physicians under audit at any time. Our data on interventional pain physicians and published data on other physicians shows that efficiency has decreased and PEs have been skyrocketing.Ironically, CMS has proposed on January 10, 2025, a 4.3% payment increase to Medicare Advantage Plans, amounting to $21 billion in 2026. To add fuel to the fire, CMS on April 7, 2025, issued a final rule of increasing on average by 5.06% from 2025 to 2026. These proposals come amid growing concerns about Medicare Advantage over payments, including $44 billion due to favorable selection, $40 billion from risk adjustment discrepancies, and $15 billion for duplicative coverage of veterans who already receive benefits through the Veterans Administration (VA). In addition, according to the Medicare Payment Advisory Commission (MedPAC), traditional Medicare beneficiaries also face higher costs, contributing an additional $198 annually, totaling roughly $13 billion per year. All of these added together, CMS is spending on Medicare Advantage over $110 billion a year.Thus, as independent practice continues to come under assault, the American Society of Interventional Pain Physicians (ASIPP) and other societies urge CMS to create a separate identifier for independent pain physicians to distinguish them from hospital-based physicians and prevent these cuts from harming independent practices. This separate but equal treatment of independent physician practices ultimately interferes with patient care.

PURPOSEOF REVIEW/OBJECTIVE:This article aims to evaluate current evidence and guidelines on anticoagulant and antiplatelet therapy for patients undergoing interventional procedures. It provides recommendations for managing these therapies with either continuation or withholding of these drugs in the perioperative period to minimize the risk of bleeding and thromboembolism in clinical practice. RECENT FINDINGS/RESULTS:Newly published guidelines and research underscore the crucial role of antiplatelet and anticoagulant therapy in interventional procedures, emphasizing the importance of decisions regarding whether to continue or temporarily stop these medications. Studies have categorized procedures into low-, moderate-, and high-risk groups, offering specific guidance on managing anticoagulant and antiplatelet therapy accordingly. The American Society of Interventional Pain Physicians (ASIPP) has developed consensus guidelines based on a synthesis of the best available evidence, incorporating risk stratification and practical recommendations. This review provides an in-depth analysis of medical, surgical, and interventional pain management literature. It highlights the updated ASIPP guidelines and summarizes the society's evidence-based recommendations for clinical practice.

BACKGROUND:Complex Regional Pain Syndrome (CRPS) is a challenging and often disabling condition marked by persistent pain, most commonly in a limb following injury or surgery. It presents with a wide array of symptoms, including intense pain, swelling, alterations in skin color and temperature, motor dysfunction, and trophic changes such as skin and tissue atrophy. While the precise cause of CRPS is not fully understood, it is thought to stem from abnormal nervous system activity, leading to heightened pain sensitivity and inflammatory responses. A thorough understanding of CRPS is essential for accurate diagnosis, effective treatment, and enhancing patients' quality of life.Although attempts have been made to distinguish between acute and chronic CRPS, there are currently no established diagnostic criteria specific to chronic CRPS in medical literature. OBJECTIVE:This ASIPP guidance document offers updated, evidence-based recommendations for the diagnosis and management of Chronic Complex Regional Pain Syndrome (CRPS), with a primary focus on introducing novel, time-based diagnostic criteria specific to the chronic phase. These proposed criteria address significant gaps in the current literature, where existing standards, such as the Budapest Criteria, do not sufficiently differentiate between the acute and chronic stages of the condition. METHODS:An expert panel convened by the American Society of Interventional Pain Physicians (ASIPP) conducted a comprehensive literature review and employed a structured consensus process to develop recommendations. Acknowledging that the clinical and pathological characteristics of CRPS change significantly beyond 12 months, the panel proposed chronic-specific diagnostic criteria based on disease duration, clinical history, physical examination findings, and optional diagnostic tests. These draft criteria were refined through multidisciplinary input and expert consensus. RESULTS:The diagnostic framework for chronic CRPS consists of four key components:General Criteria - Require fulfillment of the Budapest Criteria for at least 12 months, continued recognition of CRPS as a diagnosis of exclusion, and differentiation from generalized nociplastic pain syndromes.History-Based Criteria - Mandate the presence of at least three out of five specific historical features.Physical Examination Criteria - Include asymmetric limb findings, sensory disturbances, and musculoskeletal changes.Optional Diagnostic Testing - May involve assessments such as intraepidermal nerve fiber density (IENFD) and imaging evidence of regional bone demineralization.This framework builds upon the Budapest Criteria by incorporating time-dependent features of chronic CRPS, including musculoskeletal dystrophy, neurogenic inflammation, and sympathetic dysfunction. Emerging objective tools-such as quantitative sensory testing (QST), skin biopsy for IENFD, functional MRI, and serum biomarkers of neuroinflammation-may further support diagnosis in complex or uncertain cases.Treatment recommendations highlight a multimodal strategy that integrates physical rehabilitation, pharmacologic management of neuropathic pain, sympathetic nerve blocks, and advanced neuromodulation. Emphasis is placed on individualized care pathways tailored to disease stage and patient-specific characteristics. CONCLUSIONS:This article presents the first structured, time-sensitive diagnostic criteria for chronic CRPS, aimed at improving diagnostic accuracy and informing treatment strategies. Adoption of these criteria may enhance clinical outcomes and promote further research into the natural history and pathophysiology of CRPS progression.

BACKGROUND:The use of facet joint interventions for spinal pain management experienced rapid growth between 2000 and 2010, with an annual increase of 14.2%. However, this trend slowed significantly from 2010 to 2019, with a reduced growth rate of just 2.9% annually. A more recent analysis highlighted a steep decline in facet joint interventions and sacroiliac joint injections, with an overall decrease of 33.2% and an annual decline rate of 12% per 100,000 Medicare beneficiaries between 2019 and 2022. OBJECTIVE:This study aims to update and analyze utilization patterns of facet joint interventions for chronic pain management in the U.S. Medicare population over three periods: 2000-2010, 2010-2019, and 2019-2022. STUDY DESIGN/METHODS:A retrospective cohort study analyzing utilization trends and influencing factors for facet joint interventions in the FFS Medicare population in the United States from 2000 to 2022. METHODS:Data were obtained from the Centers for Medicare & Medicaid Services (CMS) physician/supplier procedure summary database (2000-2022). Utilization rates were calculated based on Medicare beneficiaries for each year and expressed as procedures per 100,000 beneficiaries. Episodes or procedural visits included only primary codes, while services encompassed all procedure levels, including add-on codes. RESULTS:Utilization patterns showed substantial fluctuations. From 2000 to 2010, facet joint intervention rates grew at 14.4% annually, slowing to 2.2% from 2010 to 2019. The COVID-19 pandemic led to a 19.3% decline in episodes. From 2019 to 2022, episodes of facet joint interventions decreased by 21.2% per 100,000 beneficiaries, while the rate of services dropped by 37%, with an annual decrease of 14.3%. Specific declines included lumbar and cervical facet joint injections (38.8% and 40.2%, respectively) and lumbosacral and cervicothoracic facet joint neurolysis (33.6% and 30.8%, respectively). The reduction in facet joint injections and nerve blocks was greater than that observed for neurolytic procedures. LIMITATIONS/CONCLUSIONS:Data were limited to the FFS Medicare population and were available only through 2022, excluding patterns for Medicare Advantage Plans, which covered nearly half of Medicare enrollees in 2022. Additionally, this study shares the common limitations of retrospective claims-based reviews. CONCLUSION/CONCLUSIONS:This retrospective analysis reveals a substantial decline in facet joint intervention episodes, with an overall decrease of 21.2% per 100,000 Medicare beneficiaries and an annual decline rate of 7.6% for episodes from 2019 to 2022.

BACKGROUND:The analysis of epidural procedure utilization has revealed several notable trends over recent years. Utilization increased significantly until 2004, then rose minimally until 2011, followed by gradual declines up to 2019 in the Medicare population. The COVID-19 pandemic led to a marked 19% decline in usage from 2019 to 2020. Additionally, recent studies of interventional pain management techniques showed a 28.9% reduction in use from 2019 to 2022, leading to an average annual decline of 10.9%. OBJECTIVE:The present investigation aims to provide an updated evaluation of epidural procedure usage for chronic pain management in the U.S. Medicare population. STUDY DESIGN/METHODS:A retrospective cohort study examining utilization patterns and variables for epidural injections in the fee-for-service (FFS) Medicare population in the U.S. from 2000 to 2022. METHODS:Data was obtained from the Centers for Medicare & Medicaid Services (CMS) master database, specifically using the physician/supplier procedure summary for 2000-2022. Episodes or procedure visits were defined as one per region using primary codes only, while services included all procedure levels and any add-on codes. RESULTS:Between 2000 and 2010, epidural episodes rose by 6.7% annually but then declined by 3% each year from 2010 to 2019. The COVID-19 pandemic led to a 19.3% reduction in procedures from 2019 to 2020, followed by a partial recovery of 5.5% in 2021, then another 10.9% drop in 2022. During 2019-2022, lumbar interlaminar and caudal procedures decreased by 26.9%, while cervical/thoracic interlaminar procedures declined by 24.2%. By 2022, transforaminal procedures surpassed interlaminar procedures, reversing the trend from 2000. LIMITATIONS/CONCLUSIONS:This analysis includes data only through 2022 and is limited to the FFS Medicare population; it does not account for Medicare Advantage Plan enrollees, who made up nearly half of Medicare participants by 2022. Additionally, the study is subject to limitations inherent in retrospective claims data analysis. CONCLUSION/CONCLUSIONS:This two-decade analysis indicates significant shifts in epidural procedure utilization, with steady increases until 2010, followed by a general decline affected by COVID-19 and other contributing factors. An approximate 24% decline in epidural procedure visits for chronic spinal pain management was noted from 2019 to 2022.